The Imp.Ac.T. projectImproving Access to HIV/TB Testing for

marginalized groups

Presentation at DRID meeting EMCDDA

11 Oct. 2012 -Jenneke van Ditzhuijzen

Acknowledgments: The Project “Imp.Ac.T. – Improving Access to HIV/TB testing for

marginalized groups” (Ref.: 2009 12 01) has received funding from the European

Commission under the Health Programme 2008-2013. However, the sole responsibility for

the study lies with the author and the European Commission is not responsible for any use

that may be made of the information contained therein.

Presentation Outline

1. Describe project

2. Methods

3. Results (preliminary)

4. Discussion and recommendations

Project partnersVilla Maraini Italy, Rome Project Leader +

Implementation

Gruppo Abele Italy, Turin Implementation

Sananim Czech Rep.,

Prague

Implementation

Odyseus Slovakia,

Bratislava

Implementation

Foundation

De Regenboog

Groep (FRG)

Netherlands,

Amsterdam

Project Evaluation

Project Aims

General aim:To broaden the access to HIV and TB testing, prevention, treatment

and care for vulnerable groups (PDU’s, migrant DU’s).

(“the mountain comes to moses”)

Specific objectives:1. Development of framework (guidelines/tools)

2. Increase access to HIV and TB testing for PDU’s and migrant DU’s

3. To ensure treatment for HIV/ TB for PDU’s and migrant DU’s

4. To promote healthier ways of life and risk reduction among PDU’s

and migrants

5. To assess the effectiveness of HIV/ TB ‘street testing’ in terms of

proportion of new infections identified

Important to know…

• Imp.Ac.T. is a PILOT project

• Start from scratch: development, implementation and

evaluation in 2 years

• Recruitment, testing, counseling and data collection

all done by low threshold services staff

• Tools developed in meetings and with advice

• Advisory Board: members from EAHC, EMCDDA, ECDC,

WHO Europe, L. Spallanzani, IFRC, and others.

Activities

• Phase 1: Development 9/2010 - 5/2011• Recruitment method

• Pre- and post test counseling

• Questionnaire

• Database

• Testing methods

• Follow up methods

• Focus groups topic lists

• Training staff (manual)

• Phase 2: Implementation 5/2011 - 6/2012

• Phase 3: Evaluation - reporting 6/2012 - 11/2012

Method: recruitment

• Recruitment by low threshold service staff

• On streets, in needle exchange

• Promotion: information flyers, posters

• Response Monitoring Form

• Eligibility

• Willingness

• Basic demographics

Method: counseling

• According to international (WHO) guidelines

• Information & motivation

• After testing: also education

preventive hygiene

WHO (2010). Scaling up HIV testing and counseling in the WHO European Region as an essential

component of efforts to achieve universal access to HIV prevention, treatment, care and support.

Policy framework.

Method: HIV testing

• Rapid test DETERMINE HIV 1/2

• High sensitivity (100%) and specificity (99.75%)

• Result in 20 minutes

From www.determinetest.com

Method: TB testing

1. Clinical screening: Risk assessment (+

physical examination) by doctor/ nurse

2. Sputum collection: in case of positive

screening; 2 sputum samples at different

times

3. Lab result in 3-6 weeks

Note:

• Active (not latent) TB test

• In Prague no sputum test but

referral to X-ray

Method: Questionnaire

• Based on DRID-tool and other

similar questionnaires

• Administration in waiting time for

HIV test results

• Follow up questionnaire

• Database:

• Developed by VM on website

• Survey tool developed by

Sananim for direct

administration

Method: FOCUS GROUPS

• First train-the-trainer (partners)

• Staff training

• 1 moderator, 1 observer

• Audio recorded

• Reporting format: Summary and exact quotes

• Topics introduced with open questions

• Guide discussion (without adding to it)

• No mention of project

• Education after FG

Method: FOCUS GROUPS

• 4 focus groups per city

• T1: 2 before implementation (1 HIV, 1 TB)

• T2: 2 after implementation (1 Imp.Ac.T.

Participants, 1 others)

• Topics

• Knowledge on TB/HIV

• Access to facilities

• After implementation: perceived behaviour

change

• After implementation: evaluation by

participants

Presentation Outline

1. Describe project

2. Methods

3. Results (preliminary)

4. Discussion and recommendations

Preliminary results Sample sizeThis image cannot currently be displayed.

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Preliminary results

Socio-demographics (PDU):

• Mostly male (73%), 25-34 years old (41%), often homeless (43%),

secondary school education level (50%), unemployed (67%) or

undeclared work/sex worker (17%).

• Small percentages of migrants in Bratislava (3%) and Prague (6%),

higher in Rome (16%) and Turin (25%).

•Non-pdu’s are slightly more often homeless or sex worker.

Preliminary results

HIV test resultsThis image cannot currently be displayed.

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Preliminary results

TB test resultsThis image cannot currently be displayed.

Preliminary results

Descriptives HIV+ people (n=19)This image cannot currently be displayed.

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Preliminary resultsBehavioural data: Drug Use

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Preliminary resultsBehavioural data: Risk behaviour

• Needle sharing

• ever: 60% (from 38% in Rome to 77% in Bratislava)

• last 4 weeks: 13% (from 10% in Rome to 28% in Bratislava)

• At follow up 15% was still sharing needles!

• Prison

• 52% has ever been in prison

• 25 % has injected drugs in prison

• Condom use

• sex workers and their clients ‘about half the time’ to ‘mostly’ (m=3.6)

• casual partners ‘occasionally’ to ‘about half the time’ (m=2.7)

• STD infection last 12 months: 6%

Preliminary resultsBehavioural data: HIV testing behaviour

•79% had HIV test before (Bratislava lowest 55%)

• Reasons NOT to get tested (barriers)

• I don’t think I’m infected (284)

• Other priorities; e.g., scoring drugs (78)

• I’m afraid to do the test (51)

• Institutional barriers NOT IMPORTANT AT ALL ,only in Turin (a bit, mainly

migrants)

• Intention to continue retesting regularly: 72% ‘yes/ quite likely’

• HIV risk behaviour change: 60% ‘not at all’

Preliminary resultsBehavioural data: TB testing behaviour

• 49% vaccinated for TB, another 26% possibly

vaccinated

• TB tested before: 53%

• Reasons NOT to get tested (barriers)

• I don’t think I’m infected (766)

• Other priorities; e.g., scoring drugs (188)

• Again, institutional barriers NOT IMPORTAN

• Intention to continue retesting regularly: 22% ‘yes/ quite likely’

• TB knowledge change: 78% ‘not at all’

Preliminary resultsFocus groups

• Poor knowledge on TB “disease from the past”

• Rich knowledge on HIV “we know more than non-users”

• Barriers: not institutional, but in themselves: “I will go

tomorrow”

• No behaviour change between T1 and T2

• Positive evaluation of project (incentives!)

• Should be continued

• Add HCV test (instead of TB?)

Summary and Discussion

• HIV

•19 new infections found in 2191 PDU’s

• 16 new infections found in 1809 recent IDU’s -->

less than 1% incidence

• No TB infection - why not?

• only active TB after screening; low accuracy of

sputum test???

•TB prevalence seems low???

• relatively small migrant population???

So.... What about the project aims?General aim:

To broaden the access to HIV and TB testing, prevention, treatment and care

for vulnerable groups ((P)DU’s, migrant DU’s).

Specific objectives:

1. Development of framework (guidelines/tools)

2. Increase access to HIV and TB testing for PDU’s and migrant DU’s

3. To ensure treatment for HIV/ TB for PDU’s and migrant DU’s

4. To promote healthier ways of life and risk reduction among PDU’s and

migrants

5. To assess the effectiveness of HIV/ TB ‘street testing’ in terms of

proportion of new infections identified

We reached objectives 1, 2 and 5

3 and 4 partly: Ensuring treatment is a challenge

Changing health behaviour is a slow process

Lessons and recommendations

Value of Imp.Ac.T. Project

• example of ‘street’ intervention/data collection combi

• social workers as interviewers

• interviewing improved relationship with clients

Improvements

• conflicting role interviewer - social worker

• response monitoring: a lot of work!

• TB very hard to diagnose, no rapid test for active TB

• baseline data and good preparation essential (involve experts!)

• computer-assisted survey tool recommended